Provider Demographics
NPI:1730255050
Name:LACKEY, JAMES MANNING (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:MANNING
Last Name:LACKEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1045 CENTRAL PARKWAY NORTH
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-5024
Mailing Address - Country:US
Mailing Address - Phone:210-541-4500
Mailing Address - Fax:210-541-4508
Practice Address - Street 1:2235 THOUSAND OAKS DR
Practice Address - Street 2:SUITE #117
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-3966
Practice Address - Country:US
Practice Address - Phone:210-490-1000
Practice Address - Fax:210-496-3590
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL5014207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX216649801Medicaid
TX216649802Medicaid
TXY29190OtherUPIN NUMBER
TXL5014OtherTX LICENSE NUMBER
TX8CJ355OtherBLUECROSS BLUESHIELD
TX216649802Medicaid
TXTXB103936Medicare PIN